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1 SOUTHSIDE INDEPENDENT SCHOOL DISTRICT Pre-K Registration REGISTRATION FOR PRE-K Preschool for ALL Four-year-olds and Head Start Eligible Four-year-olds Date April 27 May 1, 2015 May 4 May 8, 2015 April 28 and May 7, 2015 Time 8:00 am 4:00 pm 8:00 am 4:00 pm 8:00 am 7:00 pm Registration Process 1) Parents pick up registration packet at your elementary school 2) Parents take packets home and complete all forms 3) Parents return packet to elementary school by May 8, 2015, with required documents REQUIRED PROOF OF RESIDENCY FOR ALL ENROLLEES Valid Texas Driver License or Texas ID or Military ID. Identification cannot be expired and has to display current address within the district. Current CPS Bill must be in parent/guardian s name and must provide physical address or rental/lease agreement valid for school year that contains the following: date of the agreement; leaser s name and signature; lessee s name and signature; and terms of the lease/rental agreement. RESIDENCY AFFIDAVITS: Power Of Attorney, Double Occupancy, or Grandparent Agreement If you require a Residency Affidavit for your child to be enrolled in the school year, then all parties are required to be present to complete the residency forms and have them notarized. A notary is available at each campus free of charge. Students who were enrolled with a Residency Affidavit in will have to complete a new residency affidavit. Forms to Complete (Included in packet): Student Registration Form Southside ISD Health History Card Parent Information Release Authorizations PEIMS Data Standards: Ethnicity and Race Reporting Student Residency Questionnaire Parent/Guardian Military Dependent Information/Foster Care Information Home Language Survey Family Survey Computer User Agreement and Interactive Videoconference Student Media Consent and Release Form Waiver for Corporal Punishment Acknowledgement of Electronic Distribution of Student/Parent Handbook Documents to Bring with you: Birth Certificate Social Security Card (Child) Parent/Guardian Identification/Driver License Immunization Record CPS Energy Bill Additional Documents Required for Head Start Bring All that Apply: 2014 Income Tax Return/W-2/1099 TANF/Medicaid/SNAP/Food Stamps Letter Worker s Comp Letter/Unemployment Letter Grant or Scholarship Award Letter Social Security Income Statement Child Support Statement from Attorney General LEGAL DOCUMENTS If you have any other documents such as a divorce decree, guardianship court order papers, or any other legal documents, they may be turned in to your child s campus with your registration packet.

3 For Office Use Only: /_ / Entry Date STUDENT INFORMATION (Please Print- Black Ink Only): Southside Independent School District Student Registration Form County/District/Campus Number Student Social Security # Grade Student I.D. # Advisor/Teacher - Room # Name (First) (Middle) (Last) (Suffix Jr. Sr.) / / ( ) Gender Date Of Birth Age as of September 1 Area Code Home Telephone Street Address (Physical Address Required) Apt. No. Zip Code Mailing Address (If Different From Above) Apt. No. Zip Code Birth Place: Student is in the conservatorship of the Department of Family and Protective Services (DFPS): Yes No Student was previously in the conservatorship of DFPS: Yes No Has your Child received any of the following services? Check all that Apply: ( ) Bilingual ( ) ESL ( ) Gifted &Talented ( ) Special Education ( ) Migrant ( ) 504 ( ) Dyslexia ( ) Uncertain Has the student ever been enrolled in a Southside ISD school? No Yes Campus:_ Last School District of Enrollment Last School Attended City and State PARENT/GUARDIAN INFORMATION: (Place a check by whom the student resides with) Student Resides with Mother Father Both Mother and Father Legal Guardian /_ / Father/Legal Guardian Name (First) (Middle) (Last) Date of Birth Father/Legal Guardian Address Address: Work: (_ ) Cell: ( )_ Father/Legal Guardian Employer/Occupation /_ / Mother/Legal Guardian Name (First) (Middle) (Last) Date of Birth Mother/Legal Guardian Address Work: (_ ) Cell: (_ ) Address: Mother/Legal Guardian Employer/Occupation Emergency Contact Information: I authorize the following individuals to pick up my child from school. / / Name Relationship Phone # Name Relationship Phone # / / Name Relationship Phone # Name Relationship Phone # Please list other children living with your family under 18 years of age: Name Foster Care Gender (M/F) Date of Birth School A person who knowingly falsifies information on a form required for enrollment of a student in a school district is liable to the district if the student is not eligible for enrollment in the district but is enrolled on the basis of the false information. Education Code (h) I certify that the information provided on this form is true and accurate. Signature of Parent/Legal Guardian Registering Student Date NOTE: If your child/ward is coming from an alternative school or has been previously expelled in another school district and the school administrator of the receiving school is not present at the time of enrollment the enrollment may be postponed until a school administrator is present. SISD FORM 4/2015

5 Southside ISD Health History Card (Clinic use only) GRADE TEACHER SOC. SEC. # Student ID# Student name Date of birth Last First MI Father'sName: Address: Cell#: Home#: Work #: ext. Mother's Name: Address: Cell #: Home #: Work #: ext. M F Emergency Contacts: These individuals can pick up my child if a parent/guardian cannot be reached: Name Relationship Phone # List the names and ages of all school-aged children living in your home: READ CAREFULLY: Please list Health Conditions and/or Previous Illnesses: See School Nurse immediately for the ADHD Epilepsy severe allergy issues listed below: Allergies (seasonal) Glasses, year Food Allergies (food/type of reaction): Asthma Hearing Loss, year Bipolar Heart Condition Cancer (type/year): Hepatitis, year Insect Allergies (insect/type of reaction) / Intellectual Disability Cerebral Palsy Rheumatic Fever Medication Allergy (type of reaction) Additional health problems not listed above (be specific): Chicken Pox, year Diabetes, Type Emotional Disturbance (list) Spina Bifida Surgery: type/year NONE / List Medication taken on a regular basis or check for NONE: Medication given at: HOME SCHOOL (See School Nurse) ** Required Name of Insurance Company: Policy #: ** Name of Child's Doctor: Phone #: ** Preferred Hospital: Phone #: If first aid is administered to my child I agree to waive any and all claims against the district and person(s) rendering first aid. If I cannot be contacted, I authorize the school to seek medical attention for my child. I certify that the information provided on this form is true and accurate, and I will keep updated. I give permission for my child's physician and the school nurse to share written or verbal information for the duration of the school year, and I understand that the nurse may share limited medical information with teachers ONLY IF NEEDED FOR STUDENT SAFETY and health maintenance. **Signature of Parent/Legal Guardian Date:

7 Immunization Requirements Pre-Kindergarten age 3 as of September 1: See family doctor or school nurse for requirements on student s age 3. Immunization Requirements for Pre-Kinder: Age 4 as of September 1 5 doses DTaP (4 th dose given at age 4) 4 doses Polio (4 th dose given at age 4) 3 doses Hepatitis B 2 doses MMR and Hepatitis A (first dose given on or after first birthday) 1 dose Hib and Varicella (on or after first birthday) PCV per schedule (see child s doctor or ask school nurse) Kinder through 12: DTaP: Five doses of diphtheria-tetanus-pertussis vaccine; one dose must have been received on or after the 4 th birthday. However 4 doses meet the requirement if the 4 th dose was received on or after the 4 th birthday. For students aged 7 years and older, 3 doses meet the requirement if one dose was received on or after the 4 th birthday. For 7th grade: 1 dose of DTaP is required if at least 5 years have passed since the last dose of tetanuscontaining vaccine. For 8th-12th grade: 1 dose of DTaP is required when 10 years have passed since the last dose of tetanusdiphtheria-containing vaccine. TD is acceptable in place of DTaP if a medical contraindication to pertussis exits. Polio (IPV): 4 doses of polio; one dose must be received on or after the 4 th birthday. However, 3 doses meet the requirement if the 3rd dose was received on or after the 4 th birthday. Measles, Mumps, Rubella (MMR): The first dose of MMR must be received on or after the 1st birthday. For K-5th grade, 2 doses of MMR are required. For 4 th -12 th grade, 2 doses of a measles-containing vaccine, and one dose each of rubella and mumps vaccine is required. Hepatitis B: 3 doses required. For student aged years, 2 doses meet the requirement if adult hepatitis B vaccine (Recombivax) was received. Dosage and type of vaccine must be clearly documented (Two 10 mcg/1.0 ml of Recombivax). Varicella: The first dose of varicella must be received on or after the first birthday. For grades K-5th and 7 th 12 th, 2 doses are required. 1 dose is required for all other grade levels. For any student who received the first dose on or after 13 years of age, 2 doses are required. Meningococcal: One dose required for 7 th 12 th grades. Hepatitis A: 2 doses for K-5 th grade. The first dose of Hepatitis A must be received on or after the first birthday.

9 Provisional Enrollment All immunizations should be completed by the first date of school attendance. The law requires that students be fully vaccinated against specified diseases. For students with an immunization record: A student may be provisionally enrolled if the student has an up-to-date record showing that the student has gotten at least one dose of each specified age-appropriate vaccine required by this rule. To remain enrolled, the student must complete the required doses in each series on schedule and as quickly as is medically possible. The updated record should be brought to the school when asked. A school nurse or school administrator will review the immunization status of a provisionally enrolled student every 30 days. If, at the end of the 30-day period, a student has not gotten the next dose of vaccine, the student is not in compliance. The school will exclude the student from school attendance until the record is up to date. If the student shot record indicates that the student is late with a vaccine or a dose in a series, the student must provide proof that he/she has received the required vaccine before he/she can be enrolled in school. If the shot record indicates that the student is fully immunized, the student will be fully enrolled without any provisions. For students without an immunization record: If a student has never attended school before or is transferring from out-of-state, the student cannot be enrolled until an immunization record is provided. Once received, the school nurse or school administrator will determine if the student can be enrolled under the provisions listed above. If a student is transferring from another school in Texas, the student may be provisionally enrolled for 30 days while waiting for transfer of the school records. Once received the school nurse or school administrator will determine if the student requires any vaccines or if he/she can be fully enrolled without provisions. If a student is homeless, the student shall be admitted temporarily for 30 days if acceptable evidence of vaccination is not available. The school shall promptly refer the student to the appropriate public health programs to obtain the required vaccines. (McKinney-Vento Act) If a student is a dependent of a person who is on active duty with the Armed Forces of the United States, the student can be enrolled provisionally for no more than 30 days if transferring from one school to another and is waiting on the transfer of the shot records. An application for Conscious Exemption for Medical or Religious Reasons can be obtained from the Texas Dept. of State Health Services by secure online form, written, or faxed request. Students will not be able to enroll until the official exemption form is signed, notarized, and submitted to the school nurse for examination. 1) Secure online request: https://webds.dshs.state.tx.us/immco 2) Mailing address: Dept. of State Health Services, Immunization Branch (MC 1946), P.O. Box , Austin, TX, ) Hand delivered request: Dept. of State Health Services, Immunization Branch, 1100 West 49 th St., Austin, TX ) Faxed request: (512)

11 Parent Information Release Authorizations Family Educational Rights and Privacy Act (FERPA) and the Texas Public Information Act Signature Page (This form must be returned to your child s teacher or the school office within the first 10 days of this school year.) According to the Family Education Rights and Privacy Act (FERPA) a Federal law, and the Texas Public Information Act, certain information about district students is considered directory information and will be released to anyone who follows the procedures for requesting the information unless the parent or guardian objects to the release of the directory information. If you do not want Southside Independent School District to disclose directory information from your child s education records without your prior written consent, you must notify the district in writing by the end of the first 10 days of instruction. Failure to return this form will result in the release of directory information upon request. A parent is allowed to record their objection to the release of all directory information on one or more specific category of directory information. Southside ISD has designated the following student information as directory information: student name, address, telephone listing, electronic mail address, photograph, and date and place of birth, as well as major field of study; degrees, honors, and awards received; dates of attendance; grade level; most recent educational institution attended; participation in officially recognized activities and sports; and weight and height of members of athletic teams. I direct the District not to release to any third party and/or for any non-school-sponsored purposes the following student information I have checked in the list below. Please return this form to your child s teacher or the school office within the first 10 days of this school year. Failure to return this form will result in the release of directory information upon request. Please check Yes or No in each category below: District Publications Southside Independent School District has my permission to release directory information for district publications, selected photography companies supporting campus pictures, and positive publicity (name and picture in yearbook, newsletters, awards, honors, PTA, booster clubs, etc.) Yes No Publications Outside the District Southside Independent School District has my permission to release directory information to any publication outside of Southside. Example: If you check the no box, any information about your child would not be released to a newspaper or magazine. Yes No Private Requestors Southside Independent School District has my permission to release directory information to any requestor in accordance with the Texas Public Information Act. Example: If you check the no box, your child s directory information will not be released to vendors or others who may be soliciting products and services. Yes No Federal law requires districts receiving assistance under the Elementary and Secondary Education Act of 1965(20 U.S.C. Section 6301 et seq.) to provide a military recruiter or an institution of higher education, upon request, with the name, address, and telephone number of a secondary student unless the parent has advised the district that they do not want the student s information disclosed without the prior written consent. Southside Independent School District has my permission to provide directory information to be released to a military recruiter. Yes No Southside Independent School District has my permission to provide to an institution of higher education with the name, address, and telephone number of my secondary student. Yes No Printed Student Name: School: Teacher/Grade Level: Parent s Signature: Date: (I understand that any checks in the NO boxes below will result in the blocking of directory information in the designated categories.)

13 PEIMS Data Standards Appendix F: Ethnicity and Race Reporting Guidance Exhibit 1A Texas Education Agency Texas Public School Student/Staff Ethnicity and Race Data Questionnaire The United States Department of Education (USDE) requires all state and local education institutions to collect data on ethnicity and race for students and staff. This information is used for state and federal accountability reporting as well as for reporting to the Office of Civil Rights (OCR) and the Equal Employment Opportunity Commission (EEOC). School district staff and parents or guardians of students enrolling in school are requested to provide this information. If you decline to provide this information, please be aware that the USDE requires school districts to use observer identification as a last resort for collecting the data for federal reporting. Please answer both parts of the following questions on the student s or staff member s ethnicity and race. United States Federal Register (71 FR 44866) Part 1. Ethnicity: Is the person Hispanic/Latino? (Choose only one) Hispanic/Latino - A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race. Not Hispanic/Latino Part 2. Race: What is the person s race? (Choose one or more) American Indian or Alaska Native - A person having origins in any of the original peoples of North and South America (including Central America), and who maintains a tribal affiliation or community attachment. Asian - A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam. Black or African American - A person having origins in any of the black racial groups of Africa. Native Hawaiian or Other Pacific Islander - A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands. White - A person having origins in any of the original peoples of Europe, the Middle East, or North Africa. Student/Staff Name (please print) (Parent/Guardian)/(Staff) Signature Student/Staff Identification Number Date This space reserved for Local school observer upon completion and entering data in student software system, file this form in student s permanent folder. Ethnicity choose only one: Race choose one or more: American Indian or Alaska Native Hispanic / Latino Asian Black or African American Not Hispanic/Latino Native Hawaiian or Other Pacific Islander White Observer signature: Campus and Date: Texas Education Agency March 2010 F.5

15 Southside Independent School District 1460 Martinez-Losoya Road San Antonio, Texas (210) x 1803 Jessica Cortes (210) x 1541 Mariana Torres (210) x 1701 Jessica Maldonado Student Residency Questionnaire This questionnaire is intended to address the McKinney-Vento Homeless Education Assistance Improvement Act 42 U.S.C STUDENT NAME: ID #: DOB: SCHOOL YEAR: CAMPUS: GRADE: Other Siblings attending Southside ISD: Name: Student ID: Grade School: Do you have any children ages 0-2 or 3-5 years old and NOT in school? Yes _No If yes, please specify age(s) 1. Do you own/rent an apartment or home? Yes (Stop & submit form) No (Continue with question #2) 2. Where is the student presently living? (Check one answer) In a shelter (emergency, family, runaway)[01] Temporarily doubled-up with another family or individual[02] Unsheltered (campsite, street, car, parks, substandard home - no utilities)[03] Motel or hotel due to loss of housing[04] CONTINUE: If you checked a box in question#2, complete questions 3, 4, & 5 below. 3. Reason for loss of housing: 4. The student lives with: 1 parent 2 parents 1 parent and another adult a relative, friend(s) or other adult(s) alone with no adult an adult that is not the parent or legal guardian 5. Name of Parent(s)Legal Guardian(s) Address: Signature of Parent/Legal Guardian Date Phone Number School Personnel: If Question #2 is checked, submit to McKinney-Vento District Liaison Mariana Torres, (fax) Jessica Cortes, (fax) Jessica Maldonado, (fax) Keep the original form for campus files. This form must be kept by campuses for audit purposes. Homeless Liaison Use Only - Fax one Copy of Approval to Food Service and one to Campus I certify the above named student qualifies for the provisions of the McKinney Vento Act. McKinney-Vento Liaison Signature Date Phone Number Presenting a false record or falsifying records is an offense under Section 37.10, Penal code, and enrollment of the child under false documents subjects the person to liability for tuition or other costs. TEC Sec (3) (d).the answers you give will help the district determine what services your child may be eligible for under the McKinney-Vento Act and/or monitored under the Angel G case for full services. Information disclosed in the residency questionnaire will not impact your enrollment at SISD. Revised 5/27/14

17 SOUTHSIDE INDEPENDENT SCHOOL DISTRICT 1460 Martinez-Losoya Road San Antonio, Texas Phone (210) Fax (210) Parent/Guardian: The Texas Education Agency is requiring the district to provide information pertaining to the identification of Military Dependent, and Foster Care families concerning Student Residency in the Public Education Information Management System (PEIMS). Please complete the information requested below and on the attached form and sign and return to your child s campus Parent/Guardian Military Dependent Information STUDENT NAME: ID #: SCHOOL YR: CAMPUS: If the parent/guardian is military please check one of the following: 0 Not a military connected student 1 Student is a dependent of a member of the Army, Navy, Air Force, Marine Corps, or Coast Guard on Active Duty. 2 Student is a dependent of a member of the Texas National Guard (Army, Air Guard or State Guard). 3 Student is a dependent of a member of a reserve force in the United States military (Army, Navy, Air Force, Marine Corps or Coast Guard). 4 Pre-kindergarten student is a dependent of an active duty uniformed member of the Army, Navy, Air Force, Marine Corps, or Coast Guard, or activated/mobilized uniformed member of the Texas National Guard (Army, Air Guard or State Guard) who was injured or killed while serving on active duty. Relationship to student: (Please check one) Father Mother Legal Guardian Signature of Parent/Guardian Date Print Name Telephone Number Foster Care Information If the student has received the following services please check one of the following: 0 Student is not in the conservatorship of Department of Family and Protective Services. 1 Student is currently in the conservatorship of Department of Family and Protective Services. 2 Pre-kindergarten student was previously in the conservatorship of Department of Family and Protective Services following an adversary hearing held as provided by Section , Family Code. Signature of Parent/Guardian Date Print Name Telephone Number Revised 4/2015

19 SOUTHSIDE INDEPENDENT SCHOOL DISTRICT Home Language Survey Grades PK-12 Name of Child Campus Grade TO BE FILLED IN BY PARENT OR GUARDIAN: PART A 1. What one language is spoken in your home most of the time? 2. What one language does your child speak most of the time? PART B (I) Place of Birth (Country of Origin) City Country Name of school last attended by the student : (II) Date of initial entry into U.S. schools: Month Day Year (III) Number of complete academic years in a U.S. school: Number of years student attended school (IV) When your child lived outside the U.S., did he or she attend school regularly? (Check one.) Yes, my child attended school regularly in all previous grades outside the U.S. No, my child missed significant portions of one or more school years, as specified: Specify grade and time period, including month and year (example: Grade 2, January 2002 through May 2002). Do not include periods of absence that lasted less than one month. Do not include regularly scheduled school holidays or vacations. Signature of Parent/Guardian Date Southside ISD Bilingual/ESL Department April 2015

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